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Claims and Appeals

In the past few years, the U.S. Federal Food and Drug Administration (FDA ) has approved “indications” for the the use of recombinant (biosynthetic) growth hormone (rhGH) for use in the treatment of Idiopathic Short Stature (ISS) and certain other indications, thus broadening the lawful uses of rhGH. At the same time, the costs to the medical insurance companies in providing an ever-increasing array of medical services and drugs, and increasing costs for those services and drugs, has resulted in competitive financial pressures within the insurance iindustry.

In cases of GHD/AGHD that involve pituitary or “classic” GHD/AGHD, a significant number of medical insurance companies control coverage and costs by requiring growth hormone stimulation tests, which are not necessarily diagnostic of GHD/AGHD in view of other criteria that is consistent with and collectively demonstrate those conditions.

In cases of functional or secondary GHD/AGHD, which include various kinds of GHD/AGD in the hypothalamic-pituitary pathway other than pituitary GHD/AGHD, including growth hormone neurosecretory dysfunction, a significant number of medical insurance companies control the coverage and costs of GHD/AGHD, in part, by (1) narrowing definitions of “medical necessity,” and “coverage,” and (2) increasing the exceptions from coverage of rhGH.

The result is the denial coverage for rhGH to a significant number of persons who “pass” the growth hormone stimulation test (GHST)–which measures only the capacity of the pituitary–because there nothing wrong with the pituitary; rather for various and often undentified reasons, those persons do not produce sufficient natural growth hormone because the pituitary does not receive the neuroendocrine message to produce to produce growth hormone.

The only way for the adult claimant or the parent or guardian of the child or adult, to contest the denial of a claim for coverage of a medical service or a drug is by following the provisions of the (1) insurance policy and any riders, (2) interpretative policies or bulletins, and (3) the procedures set forth in the employees handbook. Here, we focus on claims and appeals involving rhGH and related endocrine conditions, which include accelerated puberty. After receiving oral or written notice of denial of the claim, the first task to perform is finding out the deadline date for filing the first, and possibly the only, level of appeal. The next tasks involve the collection of medical information, the insurance documents above, and to determine who, if anyone, is going to assist you with the appeal.

These matters, and much more, are discussed in the Mini Primer on How to Handle an Appeal of Denial of Insurance Coverage for Growth Hormone Replacement Therapy (by Earl A. Gershenow, Esquire (February 11, 2007).